Hospital Authority announces incident involving no X-ray images sent from angiography machine during operation in Queen Elizabeth Hospital

The following is issued on behalf of the Hospital Authority:

     The Hospital Authority (HA) announced an incident involving no X-ray images sent from an angiography machine during an operation in Queen Elizabeth Hospital (QEH) today (September 12):

     A 66-year-old male patient with cerebellar arteriovenous malformation underwent an embolisation procedure in QEH on September 9. Under normal circumstances, the angiography machine would have shown real-time fluoroscopic screening images of the patient's blood vessels in the brain. Amid the procedure when the patient was injected with tissue glue to control bleeding from a small blood vessel, the screen of the angiography machine did not show the normal flow of tissue glue in the blood vessels. The clinician considered that the situation was unusual at the time and suspended the injection procedure immediately.

     The clinician then used the angiography machine to scan the blood vessels in the patient's brain again, and found that tissue glue was found in other blood vessels in the brain. Besides, bleeding was found in the blood vessels in the cerebellum. The clinical team then immediately stabilised the patient's condition with appropriate treatment. The patient is now in the High Dependency Unit with critical condition.

     The HA is very concerned about the adverse event related to the angiography machine during the operation and QEH will review the causes of the adverse event in different aspects including work flow and operational aspect. The equipment company subsequently arranged its staff to check the angiography machine on-site and retrieved the event log, which confirmed that the machine did not produce any X-ray when the tissue glue was injected. The exact cause of the incident is still under investigation.

     Representatives of the HA and QEH met with the equipment company on September 10 and learnt that the incident was rare and the cause had yet to be determined. The equipment company has escalated the issue to its head office. The biomedical engineers of the HA will maintain close communication with the equipment company. The HA has reported the incident to the Medical Devices Division of the Department of Health and has temporarily suspended the use of the same model of angiography machine and requested the equipment company to investigate the cause of the abnormality.

     The angiography machine in QEH has been temporarily suspended from service. Another angiography machine of the same model is also temporarily suspended at Queen Mary Hospital. The two hospitals will utilise other medical equipment for relevant procedures such that patient services will not be affected.